Provider Demographics
NPI:1750988291
Name:EGAN, STEPHANIE (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:EGAN
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RUNAWAY BAY DRIVE
Mailing Address - Street 2:BUILDING 105 APT 310
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:518-536-2353
Mailing Address - Fax:
Practice Address - Street 1:2801 TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-4630
Practice Address - Country:US
Practice Address - Phone:757-393-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008669225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist